Changes in communal provision for adult social care: 1991-2001

An investigation of the changing patterns of residential care in the UK.

This report examines shifting trends in care home provision for adults between 1991 and 2001. Adult social care policy is currently under government review and this research makes a timely contribution to our understanding of the factors which impact on residential care.

The report:

analyses detailed census data from 1991 and 2001 to reveal general trends in adult social care provision. A number of variables are used to understand these trends, including levels of local authority funded places, health and poverty indicators, property prices and provision of other types of social care;

considers the changing age, gender, ethnicity and urban/rural profile of service users.

The authors find a lack of equity in care home provision, and they conclude by raising topical questions about the future of residential care.

Due to its large size, this report is also available in two smaller segments:

Summary

This project explored changes in residential and nursing care provision between 1991 and 2001. Using Census data, the researchers looked at general trends and also at relative changes in the age, gender and ethnicity of care home residents. The researchers were Laura Banks, Philip Haynes, Susan Balloch and Michael Hill of the Health and Social Policy Research Centre, University of Brighton. They found:

Between 1991 and 2001, nursing and residential care homes in Great Britain decreased by 11 per cent. There was a slight increase in care homes in the independent sector, although both sectors declined in Wales.

Only in Scotland did the number of total care homes (local authority and independent) increase (by 11 per cent).

There was a slight increase in the independent sector in Northern Ireland (local authority data was not comparable between 1991 and 2001).

Older people in urban areas were less likely to be living in care homes. Urban areas were, however, more likely than others to support residents living in care homes in other local authority areas.

Decline tended to be greater in more deprived areas with poorer levels of health. This raises concerns that care homes are not necessarily located where there is most need.

There was no uniform association between local decreases in residential/nursing care provision and growth in home care services.

In both 1991 and 2001, older people from ethnic minorities were less likely to be living in care homes than those from the white majority population. In London, the decline in care homes had a greater proportional impact upon people from ethnic minorities.

Many Inner London boroughs had larger numbers of care home residents supported in other areas than within the local authority area in 2001. This lack of local provision may have more impact on poorer Londoners and those from ethnic minorities who may be reluctant to move away from their local community.

Coastal areas of the South West and South East of England had the lowest ratios of ‘supported residents’ to total residents, suggesting these areas may also have high numbers of residents supported by other areas.

Women were over-represented in care homes, even allowing for the trend for women to outlive men.

Background

Publication of the 2001 Census presented an opportunity to analyse the scale of residential care provision in Great Britain, to examine changes in relation to 1991 and geographical variations, such as differences between urban and rural and rich and poor areas, and what has happened in those parts of the country traditionally seen as retirement areas and previously identified as having large numbers of residential establishments. Specific aims of this study included:

to measure changes in the residential care population and the number and type of establishments 1991-2001 and to assess geographical variations in these changes;

to explore changes in care home provision in different types of geographical area;

to measure whether there were any significant changes in the gender of people in residential care and any associated geographical complexities;

to measure whether older people from ethnic minorities have the same levels of local access to residential care as other population groups, to examine changes between 1991 and 2001, and to consider associated geographical complexities;

to explore associations between changes in the pattern of residential care provision with changes in patterns of other provision.

Since, data for the statutory sector in Northern Ireland for the two Census years were not comparable, the following results apply to Great Britain only.

Key changes 1991-2001

Between the two Census years, there was a decline in the number of local authority care homes in all regions, but the trend in changes in the independent sector varied (see Figure 1). Overall there was, however, an increase in independent sector residential care homes, but a decline in nursing homes. (It should be noted, however, that there was no category of ‘dual-registration’ homes, which may distort this distinction.)

Figure 1: Percentage change in care homes between 1991 and 2001 by country and sector

The overall decline in older people (75+) living in care homes was at odds with wider demographic change, since there had been an increase in the number in this age group in all regions, except London (where there had been a slight decline). The average age of a care home resident had, however, increased. This was due to the growth in the number of people aged over 90. The only region to have seen an increase in the number of homes and residents was Scotland, whilst the greatest proportionate decline was in the North West of England and in Wales. In both 1991 and 2001, however, London was the region with the smallest proportion of older people (75+) living in care homes.

Variations between local authority areas

Local authority areas which were classed as urban experienced on average greater levels of decline and had a lower proportion of older people living in care homes than those identified as rural or mixed. In particular, decline in residential care tended to have been greater in urban areas that scored more highly on the Index of Multiple Deprivation (i.e. were more deprived) and which had poorer self-reported levels of health amongst older people. However, such local authorities were also, in 2001, more likely to be supporting residents in care homes in other areas. This was particularly the case for Inner London boroughs, many of which were identified as the greatest ‘exporters’, since they had the highest ratios of local authority ‘supported residents’ to care home residents still living within the area. Conversely, those local authorities with the lowest ratios (and thus likely ‘importers’) were in coastal areas of the South West and South East of England. High property prices were associated with decline in residential care in London and in Wales, but did not explain relatively high rates of decline in urban areas outside of London.

Gender and marital status

A large majority of care home residents were women. In 2001, 63 per cent of care home residents were women aged 75 or over. For each age group, older women were more likely to live in care homes than older men and the unmarried (including single, divorced and widowed) more likely to be living in care homes than married people. As shown in Figure 2, older women were, however, more likely than men of the same marital status and age bracket to be living in care homes, except for the 75-79 unmarried group. Younger men (under 65) were, however, more likely to live in care homes than younger women. This over-representation of men in the younger section of the care home population meant that the decline in residential care affected men less than women, since there was a slower decline in the younger section of the care home population.

Figure 2: Percentage of people living in care homes by gender, age and marital status

Ethnicity

In 1991 and 2001, the proportion of the minority ethnic population living in care homes was smaller than the proportion of the white population living in care homes. This was the case for the younger as well as for the older age groups. In particular, the Asian/Asian British group were found to be the most under-represented. In London, where 43 per cent of minority ethnic people in the UK were living (in 2001), SARs data suggests that the decline in residential care had a greater proportionate impact upon the minority ethnic population. Older people from ethnic minorities (especially the Asian/Asian British group) were also more likely to be living in larger households and in a household with one or more carer.

Relationship between residential care and other types of care

There was no uniform association between local authorities experiencing a greater decline in residential care provision and a growth in home care services. In fact, there was a tendency for local authorities supporting high levels of residential care to support relatively high levels of home care services too. This suggests that the substitution of residential care with home care was not large scale, but varied from place to place.

Data on informal care was limited. It was notable, however, that (in 2001) out of the three countries in Great Britain, Scotland had both the highest proportion of older people (75+) living in care homes and the lowest proportion of older people (in households) providing care, whilst conversely, Wales had the lowest proportion of older people living in care homes and the highest proportion of older people (in households) providing care. It was also notable that, although there had been a decline in all regions in the number of older people living in other medical/care establishments, this was particularly prominent in Scotland.

Conclusion

This research shows an overall decline in care homes and residents, but some marked variation in the independent sector. It highlights how decline in residential care has tended to affect more deprived areas with higher rates of poor health amongst older people, and that older people in such local authority areas were, in 2001, less likely to be living in a care home. In addition, it shows that areas where there had been a larger decline, particularly Inner London boroughs, tended to also be greater ‘exporters’ of care home residents.

One area of concern the research raises, therefore, is the effect that restrictions in local choice in care home provision may have on people living in such areas and how this may have had a particular impact on those from minority ethnic groups. This lack of equity in care home provision raises concern over the ability of central and local government to successfully conduct needs-based planning when dealing with market forces that are to a large extent out of government control.

About the project

This study was carried out by Laura Banks, Dr Philip Haynes, Professor Susan Balloch and Professor Michael Hill from the University of Brighton.

The research used standard table data from the 1991 and 2001 Censuses, which were aggregated to the 2001 Census areas at county / unitary authority level for analysis (although some of the analysis was also conducted at 2001 regional level). In addition, data from the 1991 and the 2001 Sample of Anonymised Records (SARs) were used for examining multivariate questions, as applied to individual respondents, such as the relationship of establishment type with age, gender, marital status and race. The project uses simple quantitative methods with bar charts, box plots, scatter plots and maps to illustrate results.